Myocardial Infarction With Non-obstructive Coronary Arteries Research Articles

The correlation of atherogenic index of plasma with non-obstructive CAD and unfavorable prognosis among patients diagnosed with MINOCA

BackgroundThe atherogenic index of plasma (AIP) is linked to lipid metabolism and has shown considerable prognostic value in cardiovascular disorders. However, its role in myocardial infarction with non-obstructive coronary arteries (MINOCA) has not been investigated. We assessed the relationship between AIP, the severity of coronary stenosis, and prognosis in MINOCA. MethodsWe included consecutive patients who were diagnosed with MINOCA. AIP was calculated using the base 10 logarithm of the ratio between the levels of TG and HDL-C. The patients were divided into four groups based on their AIP quartiles: Q1 (AIP<-0.145), Q2 (AIP≥-0.145and≤0.049), Q3 (AIP>0.049and≤0.253), and Q4 (AIP>0.253). All patients underwent follow-up for MACE. ResultsThe final analysis included 421 patients, with 188 having normal coronaries (0 stenosis) and 233 exhibiting non-obstructive coronary artery disease (CAD) (<50 % stenosis). In the multivariate logistic analysis, highest AIP (Q4) group was significantly associated with increased risk of non-obstructive CAD in MINOCA (OR,1.994;95 % CI:1.075–3.698; P = 0.029). During the follow-up period, MACE occurred in 22.8 % of MINOCA patients. Q4 group exhibited a significantly higher rate of MACE (P = 0.021). Furthermore, when both AIP and coronary stenosis status were considered, the results revealed individuals in the Q4 group with non-obstructive CAD had the highest risk of MACE (log-rank P = 0.027). The adjusted Cox analysis indicated that the Q4 group was associated with a 2.052-fold increase in the HR of MACE. ConclusionAIP exhibits a notable association with the incidence of MACE in MINOCA patients and serves as a substantial marker for non-obstructive CAD in this patient group.

Prognostic role of coronary artery ectasia in patients with nonobstructive coronary artery disease.

Coronary artery ectasia (CAE) has been linked to the occurrence of adverse events in patients with ischemia/angina and no obstructive coronary arteries (INOCA/ANOCA), while the relationship between CAE and myocardial infarction with nonobstructive coronary arteries (MINOCA) has been poorly investigated. In our study we aimed at assessing differences in clinical, angiographic and prognostic features among patients with CAE and MINOCA vs. INOCA/ANOCA presentation. Patients with angiographic evidence of CAE were enrolled at the University Hospital of Parma and divided into MINOCA vs. INOCA/ANOCA presentation. Clinical and quantitative angiographic information was recorded and the incidence of major adverse cardiovascular events (MACE) was assessed at follow-up. We enrolled a total of 97 patients: 49 (50.5%) with MINOCA and 48 (49.5%) with INOCA/ANOCA presentation. The presentation with MINOCA was associated with a higher frequency of inflammatory diseases ( P  = 0.041), multivessel CAE ( P  = 0.030) and thrombolysis in myocardial infarction (TIMI) flow < 3 ( P  = 0.013). At a median follow-up of 38 months, patients with MINOCA had a significantly higher incidence of MACE compared with those with INOCA/ANOCA [8 (16.3%) vs. 2 (4.2%), P  = 0.045], mainly driven by a higher rate of nonfatal MI [5 (10.2%) vs. 0 (0.0%), P  = 0.023]. At multivariate Cox regression analysis, the presentation with MINOCA ( P  = 0.039) and the presence of TIMI flow <3 ( P  = 0.037) were independent predictors of MACE at follow-up. Among a cohort of patients with CAE and nonobstructive coronary artery disease, the presentation with MINOCA predicted a worse outcome.

P 011: Myocardial infarction with non-obstructive coronary arteries (MINOCA) induced by stimulant ‘Kopi Jantan’

P 011: Myocardial infarction with non-obstructive coronary arteries (MINOCA) induced by stimulant ‘Kopi Jantan’

Role of cardiac magnetic resonance imaging in identifying infarct related artery and non-ischemic pathogenesis in patients presenting with non ST elevation myocardial infarction

IntroductionIdentifying an Infarct-related artery (IRA)in Non-STEMI is sometimes tricky. Besides, myocardial infarction with non-obstructive coronary arteries (MINOCA) mimickers are often labeled as myocardial infarction. Late Gadolinium enhancement (LGE) on cardiac MRI can help in identifying IRA besides MINOCA mimickers. AimsTo study the role of LGE on cardiac MRI(CMR) in NSTEMI. Material MethodsIt was a prospective observational, double-blinded study. 70 NSTEMI patients were prospectively enrolled over two years. CMR was done before coronary angiography (CAG) during the index hospitalization. Matching was done between IRA selected by CAG and IRA as determined by LGE on MRI. ResultsMean age was 58 ± 15 years. CAG could not identify IRA in 38.6% (n = 27) patients. In this patient group, LGE-CMR identified IRA in 48.1% (n = 13) & a new non-CAD diagnosis was identified in 18.5% (n = 5) patients. IRA was identified in 61.4% (n = 43) by CAG & in this patient group, LGE-CMR identified a different IRA in 6.9% (n = 3) patients. LGE-CMR also identified a new non-CAD diagnosis in 11.6% (n = 5) of patients from this group. Overall, LGE-CMR led to a new IRA diagnosis in 23% (n = 16) patients & a diagnosis of non-ischemic pathogenesis in 14% (n = 10) patients. Non-Ischemic diagnosis on CMR included stress cardiomyopathy in 3, myocarditis in 6, and infiltrative disorder in 1 patient. ConclusionCMR leads to new IRA diagnoses or non-ischemic pathogenesis in one-third of the cohort.

Long-term outcomes in very young patients with myocardial infarction with non-obstructive coronary arteries.

Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) covers an expanding group of patients over recent years. Previous studies showed considerable risks of outcomes in this group. However, there is a lack of evidence in young patients with MINOCA. In this study, we aimed to investigate the long-term outcomes in very young patients with MINOCA. We retrospectively compared the features and predictors of 183 very young (≤40-year-old) patients to >40-year-old patients with MINOCA. We compared the baseline characteristics and major adverse cardiac events (total MI, revascularization and mortality) rates between the groups during a median follow-up of 7.3 years. We performed the Cox regression analysis to investigate the risk factors for mortality. We found that the ≤40-year-old group with MINOCA had 12% mortality rates during the follow-up. They had significantly lower rates of diabetes and hypertension and higher rates of male gender and smoking compared to the older group. The very young group also had lower rates of CRF, previous MI and atrial fibrillation. The ≤40-year-old groups received significantly lower rates of medications. Ejection fraction (EF) <30% was independently associated with 6-fold increases in total mortality [hazard ratio (HR) = 6.23, 95% confidence interval (CI) 1.42-27.2, P = 0.02] in the ≤40-year-old group. In conclusion, the ≤40-year-old patients with MINOCA have substantial long-term mortality rates. EF <30% was independently associated with total mortality in this group. Moreover, the ≤40-year-old group also received less intense medical therapy compared to their older counterparts.

Association of Depression With Myocardial Infarction With Non-obstructive Coronary Arteries: A Systematic Review.

This systematic review examined the association between depression and myocardial infarction with non-obstructive coronary arteries (MINOCA). A comprehensive literature search was conducted using electronic databases, resulting in the inclusion of six small case-control and cohort studies reported from Spain, Australia, China, and Pakistan. The studies included various study designs, such as cohort studies, case-control studies, and prospective cohort studies. The results of the systematic review indicate a significant association between depression and MINOCA. Several studies reported a higher prevalence of depression among MINOCA patients compared to those with obstructive coronary artery disease. Additionally, depression was found to be associated with worse outcomes in MINOCA patients, including increased cardiovascular events, all-cause mortality, and reduced quality of life. Some studies suggest that psychological factors, such as chronic stress, inflammation, and altered sympathetic nervous system activity, may play a role in the development and progression of MINOCA in individuals with depression. The findings highlight the importance of considering depression as a potential risk factor and prognostic marker in MINOCA patients. Early identification and management of depression in these individuals may improve outcomes and quality of life. A multi-center randomized controlled trial is needed to better understand the underlying mechanisms and to develop targeted interventions for individuals with depression and MINOCA.

Clinical outcomes of myocardial infarction with non-obstructive coronary arteries presenting with diabetic ketoacidosis: a propensity score-matched analysis

Introduction and ObjectiveThere is a paucity of data on patients with myocardial infarction with nonobstructive coronary arteries (MINOCA) and a decompensated diabetic state, diabetic ketoacidosis (DKA). Therefore, we aimed to investigate the outcomes of patients with MINOCA presenting with or without DKA.MethodsWe conducted this retrospective propensity score-matched analysis from January 1, 2015, to December 4, 2022. The patients with a principal admission diagnosis of ST-Elevation MI (STEMI) and discharge labeled as MINOCA (ICD-10-CM code 121.9) with DKA were analyzed. We performed a comparative analysis for MINOCA with and without DKA before and after propensity score matching for primary and secondary endpoints.ResultsThree thousand five hundred sixty-three patients were analyzed, and 1150 (32.27%) presented with DKA, while 2413 (67.72%) presented as non-DKA. The DKA cohort had over two-fold mortality (5.56% vs. 1.19%; p = 0.024), reinfarction (5.82% vs. 1.45%; p = 0.021), stroke (4.43% vs. 1.36%; p = 0.035), heart failure (6.89% vs. 2.11%; p = 0.033), and cardiogenic shock (6.43% vs. 1.78%; p = 0.025) in a propensity score-matched analysis. There was an increased graded risk of MINOCA with DM (RR (95% CI): 0.50 (0.36–0.86; p = 0.023), DKA (RR (95% CI): 0.46 (0.24–0.67; p = 0.001), and other cardiovascular (CV) risk factors.ConclusionDKA complicates a portion of MINOCA and is associated with increased mortality and major adverse cardiovascular events (MACE).

A Case of Myocardial Infarction with Non-obstructive Coronary Arteries Complicated by a Ventricular Septal Rupture: The Challenge of Achieving Hemodynamic Stability Using Impella Devices.

The prognosis of myocardial infarction with non-obstructive coronary arteries (MINOCA) is reported to be as worse as myocardial infarction with obstructive coronary arteries. However, its mechanical complications are still poorly understood. A 71-year-old woman developed MINOCA after ascending aortic replacement surgery. During treatment, the patient experienced cardiogenic shock due to a ventricular septal rupture (VSR). The introduction of Impella devices reduced the left-to-right shunt and improved the patient's hemodynamics. Finally, a scheduled surgical repair was performed under stable conditions. In this report, we focused on the pathophysiology of MINOCA-related VSR and discussed the effectiveness of Impella devices as a bridge to surgical repair and circulatory backup during the perioperative period.

Kiosk 1R-TA-07 - Microvascular Dysfunction Assessed by Quantitative Perfusion CMR Is a Common Condition in Patients with MINOCA (myocardial Infarction with Non-obstructive Coronary Arteries) and Otherwise Normal CMR

Kiosk 1R-TA-07 - Microvascular Dysfunction Assessed by Quantitative Perfusion CMR Is a Common Condition in Patients with MINOCA (myocardial Infarction with Non-obstructive Coronary Arteries) and Otherwise Normal CMR

Reduced stress perfusion in myocardial infarction with nonobstructive coronary arteries

Myocardial infarction with nonobstructive coronary arteries (MINOCA) has several possible underlying causes, including coronary microvascular dysfunction (CMD). Early cardiovascular magnetic resonance imaging (CMR) is recommended, however cannot provide a diagnosis in 25% of cases. Quantitative stress CMR perfusion mapping can identify CMD, however it is unknown if CMD is present during long-term follow-up of MINOCA patients. Therefore, this study aimed to evaluate presence of CMD during long-term follow-up in MINOCA patients with an initial normal CMR scan. MINOCA patients from the second Stockholm myocardial infarction with normal coronaries study (SMINC-2), with a normal CMR scan at median 3 days after hospitalization were investigated with comprehensive CMR including stress perfusion mapping a median of 5 years after the index event, together with age- and sex-matched volunteers without symptomatic ischemic heart disease. Cardiovascular risk factors, medication and symptoms of myocardial ischemia measured by the Seattle Angina Questionnaire 7 (SAQ-7), were registered. In total, 15 patients with MINOCA and an initial normal CMR scan (59 ± 7 years old, 60% female), and 15 age- and sex-matched volunteers, underwent CMR. Patients with MINOCA and an initial normal CMR scan had lower global stress perfusion compared to volunteers (2.83 ± 1.8 vs 3.53 ± 0.7 ml/min/g, p = 0.02). There were no differences in other CMR parameters, hemodynamic parameters, or cardiovascular risk factors, except for more frequent use of statins in the MINOCA patient group compared to volunteers. In conclusion, global stress perfusion is lower in MINOCA patients during follow-up, compared to age- and sex-matched volunteers, suggesting that CMD may be a possible pathophysiological mechanism in MINOCA.Clinical Trial Registration: Clinicaltrials.gov identifier NCT02318498. Registered 2014-12-17.

Early diagnosis and prognosis of MINOCA by CMR

Cardiovascular disease is a prevalent health concern in contemporary society. Numerous studies have indicated that certain individuals with myocardial infarction may not obtain symptoms of coronary obstruction in coronary angiography. As a result, there is a growing interest in exploring the evaluation of myocardial infarction with non-obstructive coronary arteries (MINOCA). This article focuses on the application of cardiovascular magnetic resonance (CMR) in the diagnosis and prognosis of MINOCA. In conjunction with the pathological characteristics of MINOCA and the imaging principles underlying CMR technology, this article investigates the role of CMR in the clinical practice of MINOCA. CMR is a valuable technique employed for studying multiple aspects of the heart, including morphology, function, organization and perfusion. By applying diverse parameters and sequences, this non-invasive imaging method emerges as an essential tool for clinical diagnosis and prognosis of various cardiovascular diseases. MINOCA is characterized by insufficient blood supply to the coronary arteries or direct myocardium dysfunction with non-ST-segment elevation and normal or less than 50% stenosis in angiography. The aetiology of MINOCA encompasses a wide range of factors, while the application of CMR shows ability to enhance the diagnostic sensitivity of MINOCA, enabling better identification of the underlying cause of the symptoms and facilitating a personalized prognosis for patients.

MINOCA: A Working Diagnosis.

Cases of patients presenting with myocardial infarction (MI) without angiographic obstructive CAD are not trivial and have significant prevalence. "The Fourth Universal Definition of MI" (4UDMI) published in 2018 introduced MI with non-obstructive coronary arteries (MINOCA).The new section was of great importance as it validated the diagnosis by defining its criteria and recognizing its presence in the community and the need for further investigation. Given the nature of the diagnosis of MINOCA, coronary angiography provides limited information about prognosis and risk stratification for future major adverse cardiovascular events (MACE). Thus, additional imaging to understand the underlying etiology of MINOCA in conjunction with a better understanding of prognostic factors is necessary to expand on the current guidelines and aid in screening for possible complications, risk of MACE, and all-cause mortality. Discerning the etiology of the presentation is crucial, and physiologic studies, as well as additional imaging, are an important part of this evaluation. These modalities includeintravascular studies such as optical coherence tomography (OCT), intravascular ultrasound (IVUS), fractional flow reserve (FFR), and imaging in the form of cardiac CT (CCT) and cardiac MRI (CMR). This step is essential to target treatment regimens more efficiently. The purpose of promoting multiple imaging modalities beyond traditional angiography is to address the working MINOCA diagnosis, with the finality of identifying the specific ischemic pathophysiology. MINOCA has multiple causative mechanisms, making it a heterogeneous collection of etiologies, resulting in acute MI: atherosclerotic, and non-atherosclerotic. This literature revision demonstrates that MINOCA prevalence and mortality are not trivial, and the diagnosis affects quality of life. MINOCA presents a definitive risk of MACE without proper stratification and targeted medical therapy. Several prognostic factors of morbidity and mortality in MI-CAD patients have been identified to correlate with MINOCA patients, especially inflammatory markers. MINOCA is not an exclusion diagnosis but a working diagnosis for which further imaging studies should be performed.

A STUDY OF CLINICAL AND ETIOLOGICAL PROFILE OF PATIENTS OF MINOCA (MYOCARDIAL INFARCTION WITH ANGIOGRAPHICALLY NON OBSTRUCTIVE CORONARY ARTERIES) AMONG THE PATIENTS WITH ST ELEVATION MYOCARDIAL INFARCTION

Objective: Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) is a relatively new term that is characterized by clinical evidence of MI with normal or near-normal coronary arteries on coronary angiography. The aim of this was to document the prevalence and demographics of MINOCA in an Indian population. Methods: It is a single center study. All consecutive patients who were ≥18 years old, diagnosed with MI according to the Third Universal Definition of Myocardial Infarction, and had undergone coronary angiography were included in the study. Patients with stable coronary artery disease, unstable angina pectoris, a history of revascularization, and type 4/5 MI were excluded. Results: A total of 548 patients who were diagnosed with MI and had undergone coronary angiography were enrolled. The prevalence of MINOCA was 6.2% in the overall study population. Compared with non-MINOCA patients, those with MINOCA were younger, had a higher prevalence of the female gender, and had a history of COVID 19 infection. Also, the median left ventricular ejection fraction as seen on echocardiography and the ratio of Killip Class I status at presentation was significantly higher in MINOCA patients than in non-MINOCA patients (p&lt;0.001).

Epicardial and Pericoronary Adipose Tissue, Coronary Inflammation, and Acute Coronary Syndromes

Vascular inflammation is recognized as the primary trigger of acute coronary syndrome (ACS). However, current noninvasive methods are not capable of accurately detecting coronary inflammation. Epicardial adipose tissue (EAT) and pericoronary adipose tissue (PCAT), in addition to their role as an energy reserve system, have been found to contribute to the development and progression of coronary artery calcification, inflammation, and plaque vulnerability. They also participate in the vascular response during ischemia, sympathetic stimuli, and arrhythmia. As a result, the evaluation of EAT and PCAT using imaging techniques such as computed tomography (CT), cardiac magnetic resonance (CMR), and nuclear imaging has gained significant attention. PCAT-CT attenuation, which measures the average CT attenuation in Hounsfield units (HU) of the adipose tissue, reflects adipocyte differentiation/size and leukocyte infiltration. It is emerging as a marker of tissue inflammation and has shown prognostic value in coronary artery disease (CAD), being associated with plaque development, vulnerability, and rupture. In patients with acute myocardial infarction (AMI), an inflammatory pericoronary microenvironment promoted by dysfunctional EAT/PCAT has been demonstrated, and more recently, it has been associated with plaque rupture in non-ST-segment elevation myocardial infarction (NSTEMI). Endothelial dysfunction, known for its detrimental effects on coronary vessels and its association with plaque progression, is bidirectionally linked to PCAT. PCAT modulates the secretory profile of endothelial cells in response to inflammation and also plays a crucial role in regulating vascular tone in the coronary district. Consequently, dysregulated PCAT has been hypothesized to contribute to type 2 myocardial infarction with non-obstructive coronary arteries (MINOCA) and coronary vasculitis. Recently, quantitative measures of EAT derived from coronary CT angiography (CCTA) have been included in artificial intelligence (AI) models for cardiovascular risk stratification. These models have shown incremental utility in predicting major adverse cardiovascular events (MACEs) compared to plaque characteristics alone. Therefore, the analysis of PCAT and EAT, particularly through PCAT-CT attenuation, appears to be a safe, valuable, and sufficiently specific noninvasive method for accurately identifying coronary inflammation and subsequent high-risk plaque. These findings are supported by biopsy and in vivo evidence. Although speculative, these pieces of evidence open the door for a fascinating new strategy in cardiovascular risk stratification. The incorporation of PCAT and EAT analysis, mainly through PCAT-CT attenuation, could potentially lead to improved risk stratification and guide early targeted primary prevention and intensive secondary prevention in patients at higher risk of cardiac events.

Family history of myocardial infarction with non-obstructive coronary arteries (MINOCA)

Abstract Introduction Genetic factors play an important role in the development of myocardial infarction (MI), and a positive family history is a risk factor for MI. The significance of family history among patients with a working diagnosis of myocardial infarction with non-obstructive coronary arteries (MINOCA) is not known, and previous studies of family history in MI have not made a distinction between MINOCA and MI due to coronary artery disease (MI-CAD) based on angiographic findings. Purpose To investigate family history of MI with and without obstructive coronary arteries in patients with a working diagnosis of MINOCA. Methods A nationwide register-based case-control study of 15 462 MINOCA cases and 38 220 controls without MI with a non-obstructive coronary angiography due to chest pain, together with 204 424 MI-CAD cases, defined as MI with obstructive coronary arteries with a degree of stenosis &amp;gt;50%, between the years 1995-2020. Data from the Swedish coronary angiography and angioplasty register with information about angiographic findings was merged with information on first-degree relatives from the Swedish multi-generation register. Odds ratio (OR) was calculated with a 95% confidence interval (CI), to analyze the probability of MINOCA patients having first-degree relatives with 1) MINOCA, 2) MI-CAD, and 3) MI-CAD patients having first-degree relatives with MI-CAD. Logistic regression models adjusted for age, sex, hypertension, diabetes, hyperlipidemia and smoking status. Results A total of 161 MINOCA patients (1%) had ≥1 first-degree relative with MINOCA and the probability of having a positive family history of MINOCA did not differ compared to controls, with age and sex adjusted OR 1.08 (95% CI 0.89-1.31) and when adjusting for all covariates 1.08 (95% CI 0.87-1.34). Conversely, 1436 MINOCA patients (9%) had ≥1 first-degree relative with MI-CAD and the probability of having a positive family history of MI-CAD was higher compared to controls with age and sex adjusted OR 1.12 (95% CI 1.05-1.20) and when adjusting for all covariates OR 1.16 (95% CI 1.04-1.20). The sensitivity analysis showed that 24 972 MI-CAD (9%) patients had a positive family history of MI-CAD compared to controls, OR adjusted for age and sex 1.68 (95% CI 1.61-1.75), and OR adjusted for all covariates 1.68 (95% CI 1.60-1.75). Conclusions In this first study that examines family history of MINOCA, including data from over 250 000 coronary angiograms, a positive family history of MI-CAD was more common among patients with a working diagnosis of MINOCA compared to controls without MI and with non-obstructive coronary arteries. A family history of MINOCA was uncommon and was not associated with MINOCA. These results indicate that genetic factors and shared environmental factors within a family leading to CAD are important also for MINOCA, thus MI-CAD and MINOCA share underlying mechanisms.

Management of hospital resources for patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) - an approach to deescalate ?

Abstract Background Patients with myocardial infarction with non - obstructive coronary arteries (MINOCA) present as a main feature a non-relevant (≤ 50%) obstructive coronary artery upon angiography despite clinical symptoms related to acute coronary syndrome. Being mostly a benign syndrome with favorable clinical outcome and almost exclusively conservative treatment, it still utilizes relevant financial and capacity resources including high care monitoring and in - hospital treatment of relevant length. Regarding scarcity of resources, this entity should be put under particular consideration. Objective Our investigation focuses on the procedural and economic impact of MINOCA patients vs. "true myocardial" infarction patients and related clinical outcomes in a single - center patient collective of a large university heart center in Germany. Methods We analyzed all patients admitted to our hospital with suspected acute coronary syndrome within a 12-month period (2017 – 2018) who had a troponin elevation and received invasive coronary angiography. We collected data on in-hospital costs, procedures, clinical parameters, work-flow timelines, and other relevant parameters. Results Of a total 3021 screened patients, we included 660 patients with acute coronary syndrome. Of those, 103 patients were attributed to the MINOCA – group. 542 patients presented with a "classical" myocardial infarction, and thus formed the MIOCA (myocardial infarction with obstructive coronary arteries) group (Table 1). In - hospital mortality (MIOCA vs. MINOCA: 59 (11.1%) vs. 0 (0%) patients; p &amp;lt; 0.01), and 30 – day mortality (MIOCA vs. MINOCA: 94 (17.3%) vs. 5 (4.2%) patients; p &amp;lt; 0.01) after the clinical index event were significantly higher in the "classical" myocardial infarction group (MIOCA). Overall length of hospital stay (mean: 9.5 ± 8.7 days vs. 12.5 ± 12.7 days; p= 0.016; median: 8.0 (5 - 14) vs. 7.0 (4 - 11); p = 0.023) as well as duration of high care monitoring (mean: 2.4 ± 4.6 days vs. 4.7 ± 7.7 days; p= 0.004; median: 1.9 (1.1 – 4.4) vs. 1.5 (0.4 – 2.7);p = 0.01)) were shorter in the MINOCA group compared to MIOCAs. However, in a 12-months period, a total sum of 298.4 days was attributed to high care monitoring for MINOCA patients (Figure 1). With average and median costs of 6871.5 ± 5670.8 and 3585.2 (3461.4 – 10167.2) EUR per index, MINOCA treatment costs were lower compared to the MIOCA group (mean: 13045.9 ± 7896.9 EUR; p = 0.02; median: 5958.9 (4682.7 – 16654.9) EUR; p &amp;lt; 0.01). MINOCA treatment was not associated with a relevant profit for these expanses (mean: 198.1 ± 4329.2 EUR; // median: 0 (-1702.6 – 1405.1) EUR; p = 0.042) and a relevant share of 36.2% of the total cost was generated due to high care monitoring in these patients (Figure 1). Conclusion In light of growing scarcity of staff, financial and capacity resources MINOCA should be put under particular consideration for refining care concepts and resource allocation.Table 1Figure 1

Sex differences in patients with MINOCA: baseline characteristics and prognosis

Abstract Background The difference between men and women regarding the diagnosis and treatment of cardiovascular diseases has been an object of study during the last few years, with an underrepresentation of female patients in old studies. The epidemiology, diagnosis, and treatment of patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) has not yet been wholly elucidated up to this day. The aim of this study is to compare the characteristics and prognosis of MINOCA patients based on sex. Methods We analyzed all consecutive patients with MINOCA diagnosed at a University Hospital between 2016 and 2022. MINOCA diagnostic criteria compelled at the ESC Clinical Guidelines and the AHA Scientific Statement have been followed. Results Our sample comprises 107 patients with MINOCA, 61 male (57%) and 46 female (43%), but once the age of 80 years old was reached, MINOCA was more prevalent in women. We found the female population to have a higher prevalence of stress (usually chronic stress) and transient ischaemic attacks. On the contrary, men usually have more night shifts, psychiatric disorders, and a higher prevalence of smoking. We found no significant differences in cardiovascular risk factors (hypertension, dyslipidemia, or DM), clinical presentation, or other symptoms at admission. (Table 1). High-sensitivity troponin peak concentration was higher in women. As for the main MINOCA physiological mechanisms, we found a significantly higher prevalence of vasospasm in men and coronary artery dissection in women. There were no significant differences regarding coronary embolism, type II acute myocardial infarction (AMI), plaque rupture, or unknown mechanisms. Regarding prognosis, with a median follow-up of 45 [20-65] months, no significant differences were found between both groups for the development of in-hospital complications or mortality, nor cardiovascular readmissions, reinfarction or death from any cause (Table 2). Conclusion Unlike the previous popular perception of this disease, there are more MINOCA male patients than females in our sample, and psychiatric disorders are more prevalent in men. In octogenary people, MINOCA was more prevalent in women. At admission, symptoms and electrocardiographic parameters were very similar between both groups, while cardiac biomarkers reached higher levels in women, unrelated to coronary artery extension or the severity of left ventricular dysfunction.

Predictors for and the role of abnormal mapping values at cardiac magnetic resonance in myocardial infarction with non-obstructive coronary arteries

Abstract Background Cardiovascular magnetic resonance (CMR) plays a crucial role in the diagnostic approach of Myocardial infarction with non-obstructive coronary arteries (MINOCA), as a result of its ability to perform myocardial tissue characterization using mapping sequences. Purpose To analyze clinical and prognostic differences in MINOCA patients with and without abnormal mapping values when early CMR is performed. Methods We assessed all MINOCA cases from January 2017 to October 2021 in our Center. MINOCA was defined according to current European guidelines criteria. Acute myocarditis, Tako-tsubo syndromes and cardiomyopathies were excluded. CMR protocol included cine images, T1 and T2 mapping and late gadolinium enhancement (LGE). Abnormal mapping was considered as the presence of prolonged native T1 and T2 mapping with a specific pattern suggestive of ischemic myocardial injury. The receiver operating characteristics curve (ROC) for the detection of abnormal mapping was derivate. Multivariate logistic regression analysis was used to determine predictors of abnormal mapping. The primary outcome of major adverse cardiovascular events (MACE) in patients with and without abnormal mapping was evaluated. Results The final cohort included 198 MINOCA, 161 (81.3%) of which constituted the abnormal mapping group (M+) while the remaining 37 consisted of MINOCA without either abnormal mapping values or presence of late gadolinium enhancement (normal CMR findings, m-). The mean time delay between acute clinical presentation and CMR was 4.8 ± 1.5 days. Among the M+ group, patients were older and presented familiarity for cardiovascular disease and hypercholesterolemia more frequently compared to the m- group. At admission, the M+ group more frequently presented ST segment alterations, wall motion abnormalities (WMA) and greater left ventricular (LV) volumes, compared to the m- ones. Furthermore, the M+ group exhibit greater peak high sensitivity-Troponin I (hs-TnI) values. The ROC curve for the detection of abnormal mapping showed that peak Tn values had an excellent area under the curve (AUC) of 0.935 (95%CI 0.902-0.968), p&amp;lt;0.001. At multivariable analyses, adjusted for confounding factors, the strongest predictor of abnormal mapping was the peak hs-TnI values (OR 1.02, 95% CI 1.01-1.03, p&amp;lt;0.001). Finally, MINOCA M+ had more MACE compared to MINOCA m- (16.8% vs 2.7%, p&amp;lt;0.001) at a mean follow up time of 33.7 ± 12.0 months. Conclusion Among selected MINOCA, abnormal mapping values when early CMR is performed identify a subgroup of patients with worse clinical presentation and outcome. Some baseline characteristics (such as ST alterations, WMA and LV volumes) may support the detection of abnormal mapping. Overall, peak hs-TnI values have an excellent diagnostic performance to predict abnormal mapping values and could be useful in identifying high-risk MINOCA and the consequent need for a CMR evaluation.

Accuracy of the GRACE Score for mortality prediction in myocardial infarction with nonobstructive coronary arteries (MINOCA)

Abstract Introduction Myocardial infarction with nonobstructive coronary arteries (MINOCA) patients account for 3.5 to 15% of all myocardial infarctions. The GRACE risk score is a well-validated tool for estimating short- and long-term risk in acute coronary syndrome, but the accuracy of the risk score for prognostic stratification in patients with MINOCA remains uncertain. Purpose We aimed to investigate whether the GRACE risk score can predict mortality in a real-world cohort of patients presenting with MINOCA. Methods We retrospectively analyzed patients admitted with MINOCA in a single center. Patients who were diagnosed with myocarditis and Takotsubo syndrome were excluded from the analysis. The GRACE risk score on admission was calculated. Patients were divided into a low-intermediate risk group (≤ 140 points, 71.5%) and a high-risk group (&amp;gt;140 points, 28.5%) according to their GRACE risk scores. Receiver operating characteristic (ROC) analysis was used to quantify the accuracy of the GRACE risk score to estimate both in-hospital and one-year mortality in MINOCA patients. Results Of a total of 3721 myocardial infarction patients, MINOCA was identified in 11.6% (n=430). 313 patients had complete data for the calculation of the GRACE on admission and were included in the analysis. Mean age was 65±12 years, and 49% (n=154) of patients were male. Mean GRACE score was 125±31 points. Patients in the high-risk group were older (74±9 vs. 61±11 years, p&amp;lt;0.001), had a higher incidence of in-hospital mortality (0.4% vs. 5.6%, p=0.008), and had a higher rate of one-year mortality (2.7% vs. 19.5%, p&amp;lt;0.001), compared with the low-intermediate risk group. There were no differences regarding sex and cardiovascular risk factors between the groups. In-hospital mortality was 1.9% and one-year mortality was 7.3%. ROC curve analysis showed that the GRACE risk score has a high value in predicting in-hospital mortality (AUC ROC 0.892; 95% CI 0.798–0.986; p=0.001), and one-year mortality (AUC ROC 0.826; 95% CI 0.739–0.0.914; p&amp;lt;0.001) in MINOCA patients. (Figure 1). The overall c-statistics were similar compared with estimates obtained from patients with myocardial infarction and significant coronary artery disease: in-hospital mortality (AUC ROC 0.0.849; 95% CI, 0.807–0.891; p&amp;lt;0.001); and one-year mortality (AUC ROC 0.776; 95% CI, 0.747–0.806; p&amp;lt;0.001). Conclusions In conclusion, the GRACE risk score provides potentially valuable prognostic information on in-hospital and one-year mortality when applied to MINOCA patients.Figure 1

Biological profiling in the spectrum of acute coronary syndrome: characterizing patients from MINOCA to NSTEMI with different features of the culprit plaque

Abstract Background In the last two decades, the development of procedures and tools such as coronary angiography and optical coherence tomography (OCT) have made it possible to highlight several aspects of acute coronary syndromes (ACS), identifying multiple subgroups such as patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) and patients with Non-ST-Elevation Myocardial Infarction (NSTEMI) and ruptured fibrous cap (RFC) or intact fibrous cap (IFC) culprit lesions. The aim of the study is to better characterize the ACS spectrum by evaluating the biological profile of non-characterized NTSEMI, RFC-NSTEMI, IFC-NSTEMI, and MINOCA patients. Methods We enrolled 56 consecutive patients presenting with ACS, specifically 16 patients with non-characterized NSTEMI, 12 patients with RFC-NSTEMI, 8 patients with IFC-NSTEMI, and 20 patients with MINOCA. Biological samples were collected and stored. We performed gene expression analysis through qRT-PCR technique for 21 genes. Results Our data displayed several differences in gene expression levels involved in inflammation, cellular adhesion, extracellular matrix turnover, and oxidative stress between the groups under examination. We observed no significant difference between non-characterized NSTEMI and MINOCA for all the studied genes. Alongside, MINOCA displayed significantly lower levels of the following genes than RFC and IFC patients: CD44, GPX1, ICAM1, PLA2G7, SOD1, and VEGFA. Furthermore, when compared with IFC patients, MINOCA showed lower levels of EDN1, LGALS8, MMP1, and TNF, and non-characterized NSTEMI showed a lower gene expression of CD31, ICAM1, and PI16. Finally, CD44, EDN1, GPX1, LGALS8, NOS3, SOD1, TFRC, and VEGFA were more expressed in RFC and IFC compared to non-characterized NSTEMI patients. Conclusions Our preliminary data, besides exploring new pathways in MINOCA patients, reflects the need for characterization and patients’ stratifications in the clinical management of ACS, since no differences were observed between non-characterized NSTEMI and MINOCA. This result may indicate that a one size fits all approach is not the most suitable since a plaque could be an innocent bystander and should be treated accordingly. A precision medicine approach that recognizes the presence of obstructive plaque and defines the type of culprit plaque (i.e., RFC or IFC) could identify better treatment, for a tailored therapy, allowing better prognosis and quality of life.Figure